Conserved IFN Signature between Adult and Pediatric Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is an allergic inflammatory disease of the esophagus that occurs in both children and adults. Previous studies of affected tissue from pediatric cohorts have identified prominent signatures of eosinophilia and type 2 inflammation. However, the details of the immune response in adults with EoE are still being elucidated. To determine whether EoE in adults shares inflammatory profiles with those observed in children, we performed RNA sequencing of paired human esophageal biopsies and blood samples from adults with EoE or gastroesophageal reflux disease. Unbiased analysis of differentially expressed genes in tissue revealed a strong IFN signature that was significantly enriched in EoE patients as compared with patients with gastroesophageal reflux disease. Both type I and type II IFN-responsive genes were upregulated in adult biopsies, but not in blood. A similar increase in expression of IFN gene sets was observed in pediatric EoE biopsies as compared with non-EoE samples, and in public pediatric and adult RNA-sequencing data. Finally, we found that human peripheral CD4+ T cells from children with EoE produce IFN-γ upon activation with EoE-causal allergens. Together, this work identifies a conserved IFN signature in pediatric and adult EoE, highlighting a role for non-type 2 inflammatory networks in the disease process in humans.

Nurse-Administered Propofol Continuous Infusion Sedation for Gastrointestinal Endoscopy in Patients Who Are Difficult to Sedate.

BACKGROUND & AIMS: Patients who chronically use alcohol, marijuana, or opioids, or suffer from post-traumatic stress disorder (PTSD), can be difficult to sedate with midazolam and fentanyl, and often are referred for monitored anesthesia care during endoscopy. Nurse-administered propofol continuous infusion sedation (NAPCIS), which confers the benefit of propofol-based sedation without the added expense of anesthesia, is effective and safe for sedation of healthy patients. We investigated whether NAPCIS also is effective for patients who are difficult to sedate. METHODS: We performed a retrospective study of patients who underwent upper endoscopy or colonoscopy with NAPCIS at a single center from January 2018 through April 2018. We reviewed records from patients who were heavy users of alcohol (n = 105), daily users of marijuana (n = 267) or opioids (n = 178), had a diagnosis of PTSD (n = 91), or were none of these (controls, n = 786). We compared mean fentanyl and propofol doses (adjusted for body weight), procedure and recovery times, procedure success rates, and adverse events. RESULTS: Compared with the controls, the marijuana group required higher mean adjusted sedative doses for colonoscopies (0.6 vs 0.4 mcg/kg fentanyl and 5.0 vs 4.7 mg/kg propofol; P ≤ .025 for both) and upper endoscopies (0.8 vs 0.3 mcg/kg fentanyl and 3.7 vs 3.2 mg/kg propofol; P ≤ .021 for both), the PTSD group required a higher dose of fentanyl for colonoscopies (0.6 vs 0.4 mcg/kg; P = .009), and the alcohol group required a higher dose of fentanyl for upper endoscopies (0.7 vs 0.3 mcg/kg; P < .001). Procedure success rates were high (95.1%-100%) and did not differ significantly between the difficult-to-sedate groups and controls; mean procedure times (7.0-9.0 minutes for upper endoscopies, 21.1-22.9 minutes for colonoscopies) and recovery times (22.5-29.6 minutes) also were similar among groups. Upper endoscopies were associated with lower sedative doses and shorter procedure and recovery times than colonoscopies. Sedation-related adverse events were rare in all groups (only 26 cases total), and there were no serious complications or deaths. CONCLUSIONS: NAPCIS seems to be a safe and effective means of providing sedation for endoscopy to patients who may be difficult to sedate owing to alcohol, marijuana, or opioid use, or PTSD.

Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation.

INTRODUCTION: Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS: Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS: The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION: NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

Long-Term Outcomes of Endoscopic Papillectomy for Ampullary Adenomas.

BACKGROUND AND AIMS: Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas and has mostly replaced surgical local resection. Recent data have discussed the role of endoscopic removal of laterally spreading adenomas associated with ampullary adenomas. We evaluated our long-term results of endoscopic papillectomy for ampullary adenomas. METHODS: We retrospectively analyzed patients who underwent endoscopic papillectomy of biopsy-proven adenomas at our tertiary center between 1994 and 2017. Clinical success was defined as complete excision of an adenoma with no evidence of recurrence during follow-up, no evidence of cancer, and without the need for surgery. RESULTS: A total of 161 patients (73M/88F) with a mean age of 61 (range 19-93) were included. Mean adenoma size was 20 mm (range 5-70). In total, 114/161 patients continued endoscopic surveillance for a minimum of 6 months with a median follow-up of 30 months (range 6-283). Recurrent adenomas were diagnosed in 8 patients (7%) after a median of 36 months (range 12-138). Clinical success was 83%; 35 laterally spreading adenomas were treated, which were larger than adenomas confined to the papilla (mean size 38 mm vs 15 mm, P < 0.05) and required more piecemeal resections (77% vs 15%, P < 0.05). However, no difference was found in recurrence rates between the two groups (8% vs 4%, P = 0.26); 24/161 (15%) of patients had adverse events including bleeding (6%) and pancreatitis (7%). CONCLUSIONS: Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas, including laterally spreading ones. Long-term surveillance demonstrates low recurrence rates at expert centers.

Primary and metastatic melanoma of the GI tract: clinical presentation, endoscopic findings, and patient outcomes.

BACKGROUND AND AIMS: Melanoma incidence has increased worldwide with a concurrent rise in both primary and metastatic melanomas of the gastrointestinal tract. MATERIALS AND METHODS: This retrospective single-center case series includes patients with histopathology-confirmed primary or metastatic melanoma of the GI tract between 1998 and 2018. RESULTS: Thirty-four patients were identified for inclusion, of whom 7 were primary and 27 were metastatic cases of gastrointestinal melanoma. For both primary and metastatic cases, the majority of patients presented with frank or occult GI bleeding (57.1% and 70.4%). Primary and metastatic lesions were predominantly diagnosed endoscopically (100% and 63.0%), with 71.4% of primary lesions found at the anorectal junction and 51.9% of metastatic lesions in the small bowel. Endoscopically diagnosed lesions were either polypoid (50%) or a luminal mass (37.5%) in the majority of cases. Common features included: amelanotic (83%), ulcerated (50%), and friable (33.3%). All primary patients were treated with surgical excision or resection. Of the metastatic patients, 56% were resected. The median interval between initial primary and gastrointestinal metastases was 65 months (ranging from 1 month to 24 years). At the time of data analysis, 85.7% of primary and 29.6% of metastatic patients remained alive. CONCLUSIONS: The majority of patients in this series were diagnosed endoscopically while investigating a source of gastrointestinal blood loss. Heightened clinical suspicion and recognition of the endoscopic features of gastrointestinal melanoma during evaluation of GI symptoms in a patient with a personal history of primary melanoma are advised.

Changes in Lower Gastrointestinal Bleeding Presentation, Management, and Outcomes Over a 10-Year Span.

BACKGROUND: There are only limited data available on changes in the etiology, management, and clinical outcomes in patients with lower gastrointestinal bleeding over the past decade. STUDY: We compared 2 groups of consecutive patients hospitalized with lower gastrointestinal bleeding during 2 time periods: 2005 to 2007 (301 patients) and 2015 to 2017 (249 patients). RESULTS: Compared with the 2005 to 2007 group, the mean Charlson comorbidity index in the 2015 to 2017 group was higher (5.0±2.6 vs. 6.0±3.0, P=0.028), whereas the use of computerized tomographic angiography and small bowel capsule endoscopy was more common (12.9% vs. 58.1%, P<0.001, and 28.8% vs. 69.0%, P=0.031, respectively). In 2005 to 2007, ischemic colitis (12.0%) was the most common confirmed etiology of bleeding and diverticular bleeding the second most common (8.6%), whereas in 2015 to 2017, diverticular bleeding was the most common etiology (10.4%), followed by angiodysplasia (8.4%). Small bowel bleeding sources were confirmed more often in the 2015 to 2017 group (P=0.017). Endoscopic treatment was attempted in 16.6% of patients in 2005 to 2007 versus 25.3% in 2015 to 2017 (P=0.015). Higher rebleeding rates, longer hospitalization durations (4.6±4.3 vs. 5.5±3.4 d, P=0.019), and a higher proportion of patients needing a transfusion (62.0% vs. 78.4%, P=0.016) were noted in 2015 to 2017. CONCLUSIONS: Over a 10-year span, there were several notable changes: (1) more comorbidities in patients hospitalized for lower gastrointestinal bleeding; (2) marked increase in the use of computerized tomographic angiography and capsule endoscopy for diagnostic evaluation; and (3) longer hospitalization durations and greater need for blood transfusion, possibly reflecting the selection of sicker patients for in-patient management in 2015 to 2017.

The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital.

BACKGROUND: The utility of the American Society for Gastrointestinal Endoscopy (ASGE) grading scale assessing complexity of endoscopic retrograde cholangiopancreatography (ERCP) has not been evaluated in clinical practice. METHODS: Patients that underwent ERCP between January 2015 and December 2015 were included. Procedural difficulty was graded according to the grading system proposed by the ASGE workshop. Technical success rates and complications were recorded. RESULTS: A total of 1355 ERCPs were performed on 934 patients. Patients were equally divided with respect to gender and had a mean age of 58 years (range 29-86). 391 cases were grade 1, 2 (29%), 695 were grade 3 (51%), and 269 were grade 4 (20%). Altered anatomy was observed in 88% of grade 4 patients. Cannulation was achieved in 98% of cases graded 1-3 and in 88% of cases graded 4 (p < 0.05). Complications were recorded in 10% of all cases with post-ERCP pancreatitis (5.4%) and procedure-related bleeding (1.5%) being the more common ones. No statistically significant difference was noted between the groups with regard to complications. Three perforations were seen in grade 1-3 cases (0.3%) compared to 4 cases in grade 4 cases (1.5%), (p = 0.01). CONCLUSION: The grading system proposed by the ASGE workshop can aid in predicting cannulation success and perforation rates in ERCP. Based on this retrospective study, the most complex ERCP procedures can be achieved with encouraging rates of success. There is a need to validate our study with prospective ones performed in other high-volume centers.

Computer-Assisted Propofol Sedation for Esophagogastroduodenoscopy Is Effective, Efficient, and Safe.

BACKGROUND AND AIMS: Computer-assisted propofol sedation (CAPS) allows non-anesthesiologists to administer propofol for gastrointestinal procedures in relatively healthy patients. As the first US medical center to adopt CAPS technology for routine clinical use, we report our 1-year experience with CAPS for esophagogastroduodenoscopy (EGD). METHODS: Between September 2014 and August 2015, 926 outpatients underwent elective EGDs with CAPS at our center. All EGDs were performed by 1 of 17 gastroenterologists certified in the use of CAPS. Procedural success rates, procedure times, and recovery times were compared against corresponding historical controls done with midazolam and fentanyl sedation from September 2013 to August 2014. Adverse events in CAPS patients were recorded. RESULTS: The mean age of the CAPS cohort was 56.7 years (45% male); 16.2% of the EGDs were for variceal screening or Barrett's surveillance and 83.8% for symptoms. The procedural success rates were similar to that of historical controls (99.0% vs. 99.3%; p = 0.532); procedure times were also similar (6.6 vs. 7.4 min; p = 0.280), but recovery time was markedly shorter (31.7 vs. 52.4 min; p < 0.001). There were 11 (1.2%) cases of mild transient oxygen desaturation (< 90%), 15 (1.6%) cases of marked agitation due to undersedation, and 1 case of asymptomatic hypotension. In addition, there were six (0.6%) patients with more pronounced desaturation episodes that required brief (< 1 min) mask ventilation. There were no other serious adverse events. CONCLUSIONS: CAPS appears to be a safe, effective, and efficient means of providing sedation for EGD in healthy patients. Recovery times were much shorter than historical controls.

Optimizing duodenoscope reprocessing: rigorous assessment of a culture and quarantine protocol.

BACKGROUND AND AIMS: Iatrogenic infections related to duodenoscopes remain a top concern for medical centers where ERCP is performed. We assessed the long-term results and impact of key interventions in the optimization of a rigorous "culture and quarantine" program for duodenoscope reprocessing. METHODS: We reviewed a prospectively collected, quality assurance database of all duodenoscope cultures (n = 4307) obtained for the initial 3-year duration of culture and quarantine from 2014 to 2017 in a single U.S.-based, high-volume endoscopy center. All duodenoscopes were subject to manual cleaning and automated reprocessing and drying, followed by sampling using a modified protocol developed by the Centers for Disease Control and Prevention. Duodenoscopes were cultured per-use. RESULTS: A total of 4307 duodenoscope cultures were obtained during the study period. High-concern organisms were isolated from 33 of these cultures, resulting in a .697% high-level disinfection defect rate. Statistically significant interventions included withdrawal of a high-frequency culture-positive duodenoscope (scope A) from clinical service in addition to implementation of new manufacturer-recommended cleaning protocols. Withdrawal of a second high-frequency culture-positive duodenoscope (scope B) and a mandatory device retrofit had no effect on the observed rate of positive duodenoscope cultures. CONCLUSIONS: Withdrawal of duodenoscopes with a high rate of culture positivity and optimizing manual cleaning practices have contributed to an overall decline in the high-level disinfection defect rate. A stringent culture and quarantine protocol allowed identification of the culprit endoscopes. There remains a much-needed role for an inexpensive and highly reliable method to check on the adequacy of reprocessing given the inherent complexity of these tasks.

Young patients with sporadic colorectal adenomas: current endoscopic surveillance practices and outcomes.

BACKGROUND AND AIMS: For young individuals (age <40 years) without strong family histories that would put them at risk for genetic colorectal cancer syndromes, it is unclear if national Multi-Society Task Force surveillance recommendations apply or if endoscopists follow these guideline recommendations when such patients are incidentally found to have adenoma(s) on colonoscopy. METHODS: We reviewed records on young (age <40 years) patients, with either no family history or only a moderate family history (1 first-degree family member with colorectal cancer at age ≥50), who were found to have neoplastic polyp(s) on their index colonoscopy. We assessed the pattern of endoscopist surveillance recommendations, whether endoscopist recommendations complied with national guidelines, and compliance with surveillance recommendations. RESULTS: One hundred forty-one subjects were included, of whom 19 (13.5%) had a moderate family history of colorectal cancer. For patients with non-high-risk findings, 27.7% were asked to repeat their colonoscopy in ≤3 years and 99.0% within 5 years. Endoscopist surveillance recommendation compliance rates with national guidelines were >65.0% for low-risk neoplasia but lower for high-risk (40.0%), nonpolypoid (44.2%), and serrated neoplasia (54.2%, P < .001 for all). Subjects whose endoscopist recommendations were noncompliant with guidelines were usually recalled too early (96%). Only 24.7% of subjects were actually compliant with endoscopist surveillance recommendations. CONCLUSIONS: For young patients with neoplastic polyp(s) but no strong family history, most endoscopists complied with national guidelines and recommended repeat colonoscopy in 3 to 5 years. However, relatively few patients were compliant with repeat colonoscopy recommendations. For most cases that were noncompliant with guidelines, patients were recalled too early as opposed to too late.

The microbiology of infected pancreatic necrosis in the era of minimally invasive therapy.

We aimed to determine the microbiology of infected walled-off pancreatic necrosis (WON) in an era of minimally invasive treatment, since current knowledge is based on surgical specimens performed over two decades ago. We retrospectively analyzed a prospectively maintained database of patients who were treated for symptomatic WON using combined endoscopic and percutaneous drainage between 2008 and 2017. Aspirates from WON at initial treatment were evaluated. One hundred eighty-two patients were included with a mean age of 56 of whom 67% were male. Culture results were obtained at a median of 45 days from onset of acute pancreatitis of which 41% were infected. Candida spp. accounted for 27%; yet, multidrug-resistant organisms were found in only five patients. Approximately 64% were transferred to our institution for continuation of care. Of those, 55% were infected, most frequently with Candida spp., Enterococcus spp., and coagulase-negative Staphylococcus. Patients seen and admitted initially at our institution had milder forms of pancreatitis, fewer comorbidities, and 85% had symptomatic sterile WON. Empiric antibiotic use successfully predicted infection 70% of the time. Multivariate analysis demonstrated that elderly age, severity of pancreatitis, and prior use of antibiotics were indicators of infection. Necrotic pancreatic tissue remains sterile in the majority of cases treated with minimally invasive therapy, enabling judicious selection of antibiotics. Candida and Enterococcus spp. were common. Patients at highest risk for infection were previously treated with antibiotics and those transferred from outside institutions.

Duration of antibiotic treatment after endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis not affecting outcomes.

BACKGROUND AND AIM: Although society guidelines recommend a short course of antibiotics after drainage of walled-off necrosis (WON), the exact duration is unclear. METHODS: This is a retrospective review of patients with no prior antibiotic exposure who underwent dual-modality drainage (DMD) for sterile WON from 2008 to 2017. Patients were grouped into short duration (SD, ≤5 days) versus long duration (LD, >5 days). The main outcome was the frequency of recurrent infections. RESULTS: Sixty-one patients (25 in the SD group and 36 in the LD group) were included. Patients in the two groups had comparable age, comorbidities, and severity of disease (P = 0.89). Patients in the SD group were treated with antibiotics for a median of 3 days compared with 8.5 days in the LD group. There were no differences in recurrent febrile episodes within 30 days of procedure-44% of SD group versus 39% of LD (P = 0.69). There was also no difference in time to resolution of WON (64 days for both groups, P = 0.72) or duration of hospitalization post-DMD (SD 7.7 days versus LD 7.5 days, P = 0.42). Three cases of Clostridium difficile colitis were observed in the LD group. CONCLUSIONS: Longer course of antibiotics seems to have similar outcomes compared with shorter courses in patients with WON treated with DMD. Prolonged-course therapy may predispose to secondary infections like C. difficile colitis. A randomized controlled trial is needed to evaluate the role and duration of peri-procedural antibiotics after drainage of sterile WON.

New guidelines for use of endoscopic ultrasound for evaluation and risk stratification of pancreatic cystic lesions may be too conservative.

BACKGROUND: The role of EUS in managing asymptomatic pancreatic cystic lesions (PCLs) remains unresolved. We retrospectively evaluated EUS in risk stratification of PCLs when adhering to the most recent AGA guidelines. METHODS: Asymptomatic PCLs that were evaluated by EUS from January 2014 to December 2014 were retrospectively reviewed including associated cytology, fluid analysis, and relevant surgical pathology. Cross-sectional imaging reports were reviewed blindly by an expert radiologist using AGA risk stratification terminology. Accepted imaging high-risk features (HRF) included cyst diameter > 3 cm, dilated upstream pancreatic ducts, and a solid component in the cyst. RESULTS: We reviewed 125 patients who underwent EUS. Expert review of cross-sectional imaging resulted in a different interpretation 25% of the time including 1 malignant cyst. Ninety-three patients (75%) had no HRFs on cross-sectional imaging; 28 patients (22%) were diagnosed with 1 HRF and 4 patients (3%) had 2 HRFs. Adhering to AGA guidelines using 2 HRF as threshold for use of EUS, the diagnosis of malignant and high-risk premalignant lesions (including pancreatic adenocarcinoma, mucinous cystadenoma, neuroendocrine tumors, and IPMN with dysplasia) had a 40% sensitivity and 100% specificity. Had EUS been utilized based on a threshold of 1 HRF on imaging, malignant and high-risk premalignant lesions would have been identified with 80% sensitivity and 95% specificity. By adding EUS to radiographic imaging, the specificity for detecting carcinomas (p = 0.0009) and detection of all premalignant lesions (p = 0.003) statistically improved. Furthermore, EUS allowed 14 patients (11%) to avoid further surveillance by lowering their risk stratification. CONCLUSION: EUS remains an essential risk stratification modality for incidental PCLs. Current guideline suggestions of its utility may be too stringent. Our study justifies expert radiology review when managing PCLs. Further studies are required to identify the optimal approach to PCL management.

The First US Clinical Experience With Computer-Assisted Propofol Sedation: A Retrospective Observational Comparative Study on Efficacy, Safety, Efficiency, and Endoscopist and Patient Satisfaction.

BACKGROUND: Computer-assisted propofol sedation (CAPS) is now approved for moderate sedation of American Society of Anesthesiologists (ASA) class I and II patients undergoing routine endoscopy. As the first US medical center to adopt CAPS for routine clinical use, we compared patient and endoscopist satisfaction with CAPS versus midazolam and fentanyl (MF) sedation. METHODS: Patients who underwent elective outpatient upper endoscopy and colonoscopy with CAPS were compared with concurrent patients sedated with MF. The primary end points were patient satisfaction (measured by the validated Patient Sedation Satisfaction Index [PSSI]), and endoscopist satisfaction (Clinician Sedation Satisfaction Index [CSSI]). Secondary end points included procedural success rates, polyp detection rates, adverse events, and procedure/recovery times. Multivariable regression was used for comparative analysis. RESULTS: CAPS was utilized to sedate 244 patients, of whom 55 underwent upper endoscopy, 173 colonoscopy, and 16 double procedures. During the same period, 75 upper endoscopies, 223 colonoscopies, and 30 doubles were performed with MF on similar patients. For upper endoscopy, the procedural success rate was 98.2% for CAPS versus 98.7% for MF (P = .96), whereas for colonoscopy, the success rate was 98.9% vs 98.8% (P = .59). Colonoscopic polyp detection rate was 54.5% for CAPS and 59.3% for MF (P = .67). Procedure times were similar between CAPS and MF. For CAPS, the mean recovery time was 26.4 vs 39.1 minutes for MF (P < .001). One CAPS patient required mask ventilation, 4 experienced asymptomatic hypotension or desaturation, and 5 experienced marked agitation resulting from undersedation. For MF, 5 patients had hypotension or desaturation, and 8 experienced undersedation. For colonoscopy, the CAPS group had higher PSSI scores for sedation adequacy, the recovery process and global satisfaction, and higher CSSI scores for ease of sedation administration, the recovery process and global satisfaction. For upper endoscopy and doubles, the CAPS CSSI score was higher for the recovery process only. All P values were adjusted for confounding by using regression analysis. CONCLUSIONS: In low-risk patients, CAPS appears to be effective and efficient. CAPS is associated with higher satisfaction than MF for colonoscopies and, to a lesser extent, upper endoscopies.

Risks and Benefits of Colonoscopy in Patients 90 Years or Older, Compared With Younger Patients.

BACKGROUND & AIMS: Although the numbers of medical procedures performed on extremely elderly patients (90 years or older, nonagenarians) are increasing, there are no data on the performance, diagnostic yield, or safety of colonoscopy for these patients. We compared the performance and safety of diagnostic colonoscopy, as well as lesions detected, in nonagenarians with patients who were 75 to 79 years old. METHODS: In a retrospective study, we compared data from 76 extremely elderly patients (90 years or older) with data from 140 very elderly patients (75 to 79 years old, controls), all of whom underwent diagnostic colonoscopy from January 2010 through March 2013 at Virginia Mason Medical Center. All colonoscopies were performed by 15 endoscopists. We compared rates of colonoscopy completion, bowel preparation quality, diagnostic yield, and adverse events. RESULTS: In extremely elderly patients, more colonoscopies were performed under general anesthesia, compared with controls (P < .001). When extremely elderly patients underwent colonoscopies with moderate sedation, lower doses of midazolam and fentanyl were given, compared with controls (P < .001). Colonoscopies were completed in a lower proportion of extremely elderly patients (88.2% vs. 99.3% for controls, P < .001), and these patients had a higher incidence of inadequate bowel preparation (29.7% vs. 15.0% for controls, P = .011). Colonoscopies were also associated with cardiopulmonary events in a higher proportion of extremely elderly patients (P = .006) as well as overall adverse events, compared with controls (P = .002). A higher proportion of extremely elderly patients were found to have advanced neoplasia (28.4% vs. 6.4% of controls, P < .001) as well as any neoplasia (P < .001 vs. controls). A greater percentage of extremely elderly patients also had large lesions (P = .002) and malignancies detected by histology (P < .001 vs. controls). Eleven extremely elderly patients (14.9%) were found to have cancer or high-grade dysplasia by colonoscopy. CONCLUSIONS: In patients 90 years or older, diagnostic colonoscopy is associated with increased risk for incomplete procedure, inadequate bowel preparation, and adverse events. However, a large proportion of patients are found to have advanced neoplasia and cancer, compared with patients 75 to 79 years old.

Validation of colonoscopic findings from a structured endoscopic documentation database against manually collected medical records data.

BACKGROUND: Endoscopic documentation software can generate research data on large numbers of subjects automatically. There are increasing numbers of published studies based on endoscopic databases such as the Clinical Outcomes Research Initiative. However, no study has yet validated such data. We compared colonoscopic findings reported by an endoscopic documentation software (Provation) against manually collected medical records data from two similar patient cohorts in the same endoscopy unit. METHODS: In November 2011, our unit switched from dictation-based text documentation to the Provation system. As a quality control initiative, we collected data on 9614 patients who had undergone colonoscopies from January 2010 to November 2011, using manual electronic chart review. We compared these data against those generated by Provation on 7091 similar patients who underwent colonoscopy from November 2011 to March 2013. RESULTS: Age, sex and procedural indication distribution were similar between the Manual and Provation cohorts, as were the large (≥1 cm) polyp (7.6 vs. 8.1%; p = 0.25) and advanced neoplasia (8.3 vs. 8.2%; p = 0.80) prevalences. However, there were significant differences in the polyp (46.9 vs. 49.8%) and adenoma prevalences (31.3 vs. 26.8%; p < 0.001). Furthermore, the Manual cohort had a higher prevalence of diverticulosis and hemorrhoids, and a lower colonoscopy completion rate. Stratification by indication resulted in additional discrepancies between the two cohorts for screening and surveillance patients. There were also differences in the anatomic (right vs. left colon) distribution of large polyps. CONCLUSIONS: There were significant discrepancies between data from Provation and manually collected medical records data. Although the two cohorts were enrolled during slightly different time periods, they came from the same endoscopy unit, had the same endoscopists and indications, and demonstrated similar demographics, making it unlikely for there to be true differences between the cohorts independent of documentation method. Thus, caution is advised when using endoscopic data for research.

A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli.

BACKGROUND: Because of their complex design, duodenoscopes have been long recognized to be difficult to fully disinfect and may play a role in transmission of bacteria between patients. Recent reports of duodenoscope-associated carbapenem-resistant enterobacteriaceae transmission have confirmed these suspicions. An outbreak of a multidrug resistant strain of Escherichia coli was recently reported at our institution. Herein we report the results of our investigation and the process improvements that we deployed in an effort to contain the outbreak. METHODS: A full investigation into the environment, endoscopists, infection control practices, high-level disinfection process as well as endoscopes was undertaken in conjunction with the local county health authority and the Centers for Disease Control and Prevention. Duodenoscopes were cultured and quarantined for 48 hours until negative cultures were obtained. Ergonomic changes were made to the endoscope reprocessing area, duodenoscopes were returned for routine maintenance, and surveillance cultures were obtained from all patients undergoing ERCP. RESULTS: Between November 2012 and August 2013, 32 patients were found to harbor 1 of 2 clonal strains of multidrug-resistant E coli, all of whom had undergone ERCP or duodenoscopy. A total of 1149 ERCPs were performed during this time period. Seven patients died within 31 days of the organism being identified in culture, 16 patients died overall by March 2015. The exact contribution of E coli to death is unclear because most patients had underlying late-stage malignancy or other severe medical comorbidities. No breach in high-level disinfection protocol or infection control practices was identified. The clonal strain of E coli was identified in culture on 4 of 8 duodenoscopes, 3 of which required critical repairs despite lack of obvious malfunction. The defect rate in high-level disinfection of duodenoscopes was 2% over a 1-year period. The implemented quality improvements, subsequent to which 1625 ERCPs have been performed, were successful in halting the outbreak. CONCLUSIONS: The existing manufacturer-recommended high-level disinfection protocols for duodenoscopes are inadequate. Although the ultimate solution may be a design change to the instrument, the timeline for such a change appears long and potentially difficult to exact. In the interim, a reliable method to ensure that bacterial pathogens are not present on the duodenoscope after high-level disinfection is needed.

Findings of diagnostic colonoscopy in young adults versus findings of screening colonoscopy in patients aged 50 to 54 years: a comparative study stratified by symptom category.

BACKGROUND: The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains controversial. Previous studies on the prevalence of neoplasia or other serious pathology in young patients mostly have been uncontrolled, providing only limited data on the risk associated with specific symptoms. OBJECTIVE: To compare colonoscopy findings in patients aged <50 years who have various symptoms (diagnostic cohort) against those of concurrent patients aged 50 to 54 years who are asymptomatic (screening cohort). DESIGN: Retrospective controlled cohort study. SETTING: Teaching hospital. PATIENTS: Symptomatic patients aged between 18 and 49 years and asymptomatic patients aged between 50 and 54 years. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Prevalence of advanced neoplasia. RESULTS: During the study period, 1638 patients underwent colonoscopy in the screening cohort (mean [± standard deviation{SD}] age 51.7 ± 1.4 years) and 1266 underwent colonoscopy in the diagnostic cohort (40.4 ± 8.0 years). Despite the age difference, the prevalence of advanced neoplasia in patients with rectal bleeding was comparable with that in the screening controls: 28 of 472 (5.9%) versus 113 of 1638 patients (6.9%) (P = .459). Furthermore, 10 patients (2.1%) with rectal bleeding were newly diagnosed with inflammatory bowel disease. In contrast, other symptoms that commonly lead to colonoscopy, such as abdominal pain, changes in bowel habits, and weight loss, were associated with much lower risks for neoplasia. As a result, the overall prevalences of neoplasia and advanced neoplasia were significantly higher in the screening cohort than in the diagnostic cohort: 467 of 1638 patients (28.5%) versus 179 of 1266 patients (14.1%), and 113 patients (6.9%) versus 48 patients (3.8%), respectively (both P < .001). LIMITATIONS: No data on duration of symptoms; discrepant sex ratios between cohorts. CONCLUSION: The threshold for diagnostic colonoscopy in symptomatic young adults should be individualized for each symptom category. Rectal bleeding warrants colonoscopy to detect advanced neoplasia or inflammatory bowel disease in most young patients, especially those aged 40 to 49 years, whereas non-bleeding symptoms, including some traditionally regarded as "alarm" symptoms, were associated with a much lower risk for neoplasia compared with the risk in screening patients aged 50 to 54 years.

Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: comparison of pancreatic cancer and nonpancreatic cancer.

BACKGROUND: Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies predominantly involving patients with pancreatic adenocarcinoma. OBJECTIVE: To compare survival and clinical outcome after stent placement for GOO due to pancreatic cancer compared with nonpancreatic cancer. DESIGN: Retrospective study. SETTING: Single tertiary hospital. PATIENTS: A total of 292 patients with malignant GOO. INTERVENTION: Stent placement. MAIN OUTCOME MEASUREMENTS: Post-stent placement survival and clinical outcome. RESULTS: In 196 patients with pancreatic cancer and 96 with nonpancreatic cancer, median post-stent placement survival was similar (2.7 months in pancreatic cancer vs 2.4 months in nonpancreatic cancer). Overall survival was shorter in patients with pancreatic cancer (13.7 vs 17.1 months; P = .004). Clinical success rates at 2 months (71% vs 91%) and reintervention rates (30% vs 23%) were comparable. Post-stent placement chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups (pancreatic cancer: chemotherapy vs no chemotherapy, 5.4 vs 1.5 months, P < .0001; metastasis vs no metastasis, 1.8 vs 4.6, P = .005; nonpancreatic cancer: chemotherapy vs no chemotherapy, 9.2 vs 1.8, P = .001; metastasis vs no metastasis, 2.1 vs 6.1, P = .009). LIMITATIONS: Retrospective study. CONCLUSIONS: In this large series of patients undergoing stent placement for malignant GOO in North America, we observed no difference in post-stent placement survival despite better overall survival in patients with nonpancreatic cancer. GOO is a marker for poor survival in malignancy, regardless of the type. Chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups.